North Carolina LCD: Respiratory Therapeutic Services
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| Contractor Name | CIGNA Government Services | |||||||||||||||||||||||||||||||||||||||||||||||||
| Contractor Number | 05535 | |||||||||||||||||||||||||||||||||||||||||||||||||
| Contractor Type | Carrier | |||||||||||||||||||||||||||||||||||||||||||||||||
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| LCD Database ID Number | L27472 | |||||||||||||||||||||||||||||||||||||||||||||||||
| LCD Version Number | 1 | |||||||||||||||||||||||||||||||||||||||||||||||||
| LCD Title | Respiratory Therapeutic Services | |||||||||||||||||||||||||||||||||||||||||||||||||
| Contractor's Determination Number | 2008-001 | |||||||||||||||||||||||||||||||||||||||||||||||||
| AMA CPT / ADA CDT Copyright Statement | CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. | |||||||||||||||||||||||||||||||||||||||||||||||||
| CMS National Coverage Policy | · Section 1862(a)(1)(A) of Title XVIII of the Social Security
Act. · Section 1833(e) of Title XVIII of the Social Security Act · 42 CFR 485.70, Personnel Qualifications · CMS Transmittal No. AB-00-39, May 1, 2000, consolidates CMS Program Memoranda for outpatient rehabilitation therapy services. · CMS Transmittal No. AB-98-14 (April 1998) addresses The National Institute of Health's National Emphysema Treatment Trial (NETT). · Pub. 100-3, Medicare National Coverage Determination Manual, Sections 170.1 and 240.7 |
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| Primary Geographic Jurisdiction | NC | |||||||||||||||||||||||||||||||||||||||||||||||||
| Oversight Region | Region IV | |||||||||||||||||||||||||||||||||||||||||||||||||
| Original Determination Effective Date | For services performed on or after 10/15/2008 | |||||||||||||||||||||||||||||||||||||||||||||||||
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| Indications and Limitations of Coverage and/or Medical Necessity | Note: This LCD pertains only to the respiratory therapy services,
G0237, G0238, and G0239. There is no specific Medicare Part B benefit
for so-called "pulmonary rehabilitation services," except
as defined in the Comprehensive Outpatient Rehabilitation Facility
(CORF) benefit. This policy does not address those. However, to
qualify and be payable, those particular services may only be performed
in a CORF. Also, various components of a program for so-called "pulmonary rehabilitation" may be performed and billed as Physical Therapy services, by licensed Physical Therapists or Occupational Therapists, using appropriate CPT codes from the Physical Therapy family of codes (CPT 97001 - 97530, as applicable). This policy does not directly address those services. The usual reasonableness and medical necessity criteria, as well as certification and re-certification requirements, do apply to those services. Medicare will consider respiratory therapeutic services medically necessary when all of the following criteria are met: 1. There must be a specific written order by a licensed physician, who has training and/or experience in the treatment of patients with pulmonary disease (i.e., the physician who is treating the patient for the pulmonary disease). The treating physician orders, supervises, guides, and directs each patient's plan of care. All treatment orders for respiratory therapies must include the following: · Be specific as to the type, frequency, and duration of the procedure, modality, or activity and individualized for the patient · Verbal and telephone orders must be co-signed and dated by the physician prior to billing the claim · A blanket respiratory therapy or pulmonary rehabilitation order is not acceptable; 2. The diagnosis must indicate a specific illness/injury or chronic pulmonary disease (See "ICD-9 Codes That Support Medical Necessity") and the patient is not actively involved in aggravating the existing disease state (i.e., patient may not be smoking or will participate in smoking cessation activities); 3. The service(s) provided must be consistent with the severity of the patient's documented illness and be reasonable in terms of modality, amount, frequency, and duration of treatment; 4. Expectation of measurable improvement in a reasonable and predictable timeframe must be indicated; 5. The patient must be physically able, motivated and willing to participate in the respiratory therapy; as well as, be a candidate for self-care; and 6. Pulmonary Function Tests (PFT's) within twelve months of initiating respiratory services with the most recent values demonstrating DLCO, FVC or FEV1 <60% of predicted or consistently symptomatic COPD with FEV1 < 2 liters. G0237 and G0238 are time based codes. The actual times spent providing the service(s) must be documented, for each individual code and service. The times must not overlap. Coverage of these services does not apply to activities performed in a fitness center, spa or commercial gymnasium unless the facility is specifically contracted for the activities by the provider, and all supervision criteria and medical necessity criteria are met. All personnel rendering these services must meet competency and quality standards acceptable to this contractor, regardless of the site of service. Such standards will include, at a minimum, certification by the American Association of Respiratory Care (or equivalent) and BCLS/ACLS certification. This applies regardless of the location where the service is provided. If the personnel rendering the services are not qualified, competent and/or appropriately credentialed, the services will be deemed not medically necessary. The services must be reasonable and individualized for each patient's condition. For respiratory therapeutic services, it is expected that no more than six (6) modalities per day would be performed per patient. Respiratory therapy procedures are usually provided 2-3 days per week for a period of 3-4 weeks, for no more than a total of twelve (12) sessions. Medical record documentation must support the need for any additional respiratory therapy sessions. The goal of these services is not to achieve a maximum exercise tolerance, but to ultimately transfer the responsibility of treatment from the clinic, hospital, or doctor to self-care in the home by the patient by: · Controlling, reducing, and alleviating the symptoms and complications of chronic pulmonary diseases · Training the patient in how to reach and maintain the highest possible level of function in activities of daily living (ADL) · Training the patient to self manage his/her daily living consistent with the pulmonary disease process Unless the patient will be able to conduct ongoing self-care at home, there will only be a temporary benefit. The endpoint of treatment, therefore, is not when the patient achieves maximal exercise tolerance or stabilizes, but when the patient or his or her caregiver is able to continue the treatment modalities at home. Treatment is individualized and supervised by the patient's attending physician (referring physician or facility medical director). Medicare does not cover on-going services of a maintenance exercise program(i.e., one where a skilled therapist's services are not medically necessary). Respiratory Therapeutic Codes: G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes (includes monitoring) G0237 should be used for therapy services to strengthen respiratory muscles. Examples are pursed-lip breathing, diaphragmatic breathing, and paced breathing (strengthening the diaphragm by breathing through tubes of progressively increasing resistance to flow). The service includes associated monitoring such as pulse oximetry, EKG, etc. G0238 Therapeutic procedures to improve respiratory function, other than described by G0237, one-on-one, face-to-face, per 15 minutes (includes monitoring) G0238 should be used for therapy services that involve a variety of activities including teaching the patient strategies for performing tasks with less respiratory effort and the performance of graded activity programs to increase endurance and strength of upper and lower extremities. G0238 does not include demonstration of the use of a nebulizer and/or inhaler, or chest percussions, since these services are represented by other CPT codes (see 94664 and 94667). G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring) G0239 represents situations in which two or more patients are receiving services simultaneously (such as those described above by G0237 and G0238) during the same time period. The practitioners must be in constant attendance, but need not be providing one-on-one contact. For example, a therapist provides medically necessary therapeutic procedures to two patients in the same exercise facility, for a 30-minute period. Both are performing different graded activities (described by G0238) to increase endurance of their upper and lower extremities while the therapist divides his/her time, in intermittent, brief episodes, between both patients. In this scenario the therapist would bill each patient for group therapy (G0239) because the treatment was provided simultaneously to two patients, and not one-on-one, as required by G0238. Monitoring provides physiologic or other data (pulse oximetry readings, electrocardiography data, measurements of strength or endurance, etc.) about the patient during the period before, during, and after the activities. An example would be pursed-lip breathing, which involves nasal inspiration followed by slow exhalations through partially closed pursed-lips to create positive pressure in upper respiratory tract, and improve respiratory muscles action. If after this training, the practitioner were to check the patient's oxygen saturation level (by pulse oximetry), peak respiratory flow, or other respiratory parameters, then this would be considered "monitoring," and would be included in the therapeutic procedure codes (G0237, G0238, G0239). |
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| Coverage Topic | Oxygen Therapy Physical, Occupational, and Speech Therapy |
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| Does the CPT 30% Coding Rule Apply? | Undefined | |||||||||||||||||||||||||||||||||||||||||||||||||
| ICD-9 Codes that Support Medical Necessity |
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| Diagnoses that Support Medical Necessity | N/A | |||||||||||||||||||||||||||||||||||||||||||||||||
| ICD-9 Codes that DO NOT Support Medical Necessity |
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| Non-Medical Necessity ICD-9 Codes Asterisk Explanation | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Diagnoses that DO NOT Support Medical Necessity | N/A | |||||||||||||||||||||||||||||||||||||||||||||||||
| General Information | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Documentation Requirements | The patient's medical record must contain documentation that
fully supports the medical necessity for respiratory therapeutic
services as covered by Medicare (see "Indications and Limitations
of Coverage and/or Medical Necessity"). This documentation
includes, but is not limited to, relevant medical history, physical
examination, and results of pertinent diagnostic tests or procedures. The appropriate certification and re-certification of the plan of care requirement applies to the services of physical therapists, occupational therapists, and speech language pathologists as described in section 1861(p) of the Social Security Act. Since it is expected that codes G0237, G0238, and G0239 will typically be provided by personnel other than physical therapists, the certification and re-certification of the plan of care requirement does not generally apply. If the services are performed by either a physical or occupational therapist (or by a therapy assistant under his or her direction), they should be billed with appropriate Physical Therapy CPT codes, and the requirement for the certification and re-certification applies. |
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| Appendices | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Utilization Guidelines | It is expected that no more than six (6) modalities of respiratory
therapeutic services would be performed per patient, per day. Therapeutic
procedures are usually provided 2-3 days per week for a period
of 3-4 weeks, for no more than a total of twelve (12) sessions.
The medical record must document the medical necessity for additional
respiratory therapy sessions (i.e., new condition, change in clinical
status). It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity. |
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| Sources of Information and Basis for Decision | Pulmonary Rehabilitation & Respiratory Therapy Servcies in
the Physician Office Setting, Birnbaum & Carlin,CHEST, 2006;
129:169 - 173 American Association of Respiratory Care (AARC), AARC clinical practice guidelines. Retrieved June 17, 2003, from the World Wide Web: www.aarc.org. American Thoracic Society (ATS), Pulmonary Rehabilitation. (1999). American Journal of Respiratory Critical Care Medicine, 159, 1666-1682. Amderican College of Chest Physicians (ACCP), Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based guidelines. Chest 1997;112, 1363-1396 Federal Register, December 31, 2002, (Volume 67, Number 251), pgs. 79965-80184. |
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| Advisory Committee Meeting Notes | Carrier Advisory Committee Meeting held on June 12, 2008. This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from various specialties. |
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| Start Date of Comment Period | 06/12/2008 | |||||||||||||||||||||||||||||||||||||||||||||||||
| End Date of Comment Period | 07/27/2008 | |||||||||||||||||||||||||||||||||||||||||||||||||
| Start Date of Notice Period | 07/28/2008 | |||||||||||||||||||||||||||||||||||||||||||||||||
| Revision History Number | Not Applicable | |||||||||||||||||||||||||||||||||||||||||||||||||
| Revision History Explanation | Not Applicable | |||||||||||||||||||||||||||||||||||||||||||||||||
| Reason for Change | Other | |||||||||||||||||||||||||||||||||||||||||||||||||
| Last Reviewed on Date | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Notes | 8/27/08 - effective date was changed to 10/15/08 from 9/15/08 on the draft version. | |||||||||||||||||||||||||||||||||||||||||||||||||
| Does this LCD contain a "Least Costly Alternative" provision? | No | |||||||||||||||||||||||||||||||||||||||||||||||||
| Related Documents | This LCD has no Related Documents. | |||||||||||||||||||||||||||||||||||||||||||||||||
| LCD Attachments | There are no attachments for this LCD | |||||||||||||||||||||||||||||||||||||||||||||||||
| Approved? | No | |||||||||||||||||||||||||||||||||||||||||||||||||
| Saved By | Lynn Hall-Tucker | |||||||||||||||||||||||||||||||||||||||||||||||||
| Saved On | 08/28/2008 07:24:18 | |||||||||||||||||||||||||||||||||||||||||||||||||
